Pruritus is a major clinical problem in patients with polycythaemia vera (PV). Conventional symptomatic treatment is unsatisfactory. Recently, a favourable effect of interferon-alpha on pruritus in patients with PV has been reported. Also, interferon-alpha suppresses the increased haemopoiesis in PV. However, long-term treatment with interferon-alpha may be hampered by side-effects and the inconvenience of chronic subcutaneous injection therapy. We conducted a long-term study (median follow-up 13 months) of the efficacy and tolerability of interferon-alpha in 15 patients (mean age 68 years) with PV and severe pruritus. Six patients were evaluable after 1 year. Pruritus significantly improved in 12/15 patients. Haematological control improved, as evidenced by a decreased number of phlebotomies from a mean of 4.3 in the year before the study to 1.8 while on interferon-alpha. Leucocyte and platelet numbers also decreased significantly. Five patients (33%) did not tolerate interferon-alpha. The effects of interferon-alpha could not be ascribed to an inhibitive effect on histamine production or to the disappearance of the abnormal erythroid progenitor clone, because erythropoietin-independent erythroid colony formation persisted during interferon-alpha treatment. We conclude that long-term interferon-alpha treatment is feasible and effectively relieves pruritus in patients with PV, but side-effects are an important concern. The optimal dose regimen that is well tolerated, relieves pruritus, and offers satisfactory haematological control at the same time remains to be established.

There is still no satisfactory explanation for the low catalytic activity of tissue factor (TF)/factor VII(a) complexes towards coagulation factor X, as found on the apical surface side of cell layers. It has been hypothesized that TF exists in a latent form. Layers of cultured human smooth muscle cells, constitutively expressing TF, were immunogold-labeled for TF in situ and processed for electron microscopy. We showed that, besides internalization and accumulation in lysosomal-like structures, TF remained associated with noncoated, flask- shaped microinvaginations of the plasma membrane. These invaginations were identified as caveolae. In regions in which intercellular contacts were interrupted, more TF-positive caveolae were observed. Enzymatically detached smooth muscle cells exhibited a similar enlargement of caveolar structures. Concomitantly, an increase of catalytic activity of apically formed TF/VIIa complexes towards factor X was found on the suspended cells. We speculate that caveolae- associated TF may function as a latent pool of procoagulant activity, which can rapidly be activated at sites in which vessel wall integrity is lost.

Twelve febrile patients with severe neutropenia, who had undergone aggressive chemotherapy for acute myeloid leukemia, were treated empirically with a continuous infusion of ceftazidime 100 mg/kg/day after a 500 mg loading dose, in order to study the pharmacokinetics of ceftazidime after continuous infusion and to examine the clinical applicability of continuous infusion in this patient population. Three patients had a slight decrease in renal function. All patients attained a steady-state ceftazidime serum level of > 20 micrograms/ml within 180 to 240 min, which was considered effective against most pathogens in neutropenic patients. The median volume of distribution for the patient group was 29.1 l, the elimination half-life was 2.5 h and the clearance of ceftazidime was 7.7 l/h. A subnormal kidney function influenced half-lives and clearance (but not volume of distribution), as expected. When precautions were taken to avoid known interactions between ceftazidime and other compounds to be infused simultaneously, continuous infusion of ceftazidime was applicable for treatment of neutropenic patients without major side effects.

Pseudothrombocytopenia may have any of a number of causes, one of which is agglutination in vitro. This phenomenon was found in samples of blood from six patients. A serum factor responsible for the agglutination was demonstrated. The factor was dependent upon the presence of EDTA and was more active at room temperature than at 37 C. It could be identified as an IgM immunoglobulin in four cases. In the other two cases definite characterization was not possible, but there was some evidence in favor of an IgM factor. All six patients had elevated serum IgM levels, but they had different and unrelated clinical disorders.

Four patients with paroxysmal nocturnal haemoglobinuria (PNH) were treated with cyclosporine. The treatment with cyclosporine was based on the hypothesis that immune-mediated bone-marrow damage is the common pathogenetic mechanism of aplasia and PNH, with lack of GPI-linked ligands for an immune attack (i.e. LFA-3, CD58) rendering PNH cells a growth advantage over other bone marrow cells. In the first patient, presenting with a mixed AA/PNH syndrome, a gradual recovery from aplasia was seen after prolonged treatment with cyclosporine. In a second patient, with a mixed AA/PNH syndrome, no haematological improvement was noted during cyclosporine administration, but this patient became transfusion-independent with increasing neutrophil and platelet counts after a course of ATG in combination with androgen therapy. Both these patients showed an increment in the proportion of neutrophils with normal expression of GPI-linked proteins concurrently with the improvement of haematological characteristics. In the two other patients, presenting with typical PNH, cyclosporine treatment did not result in any change in haematological characteristics, nor in PNH parameters. No significant change in haemolytic parameters was seen in any of the patients. It is concluded that immunosuppressive therapy may be of benefit in patients with a mixed AA/PNH syndrome. This effect became apparent after prolonged treatment with cyclosporine in one patient, and after a subsequent course of ATG with concomitant androgen therapy in another.

SummaryThe effect of induced hypothyroidism on platelet count and platelet volume distribution was studied in twelve athyreotic patients, After a two weeks withdrawal of triiodothyronine supplementation, platelet count and the ratio between platelet and red cell count were increased in all patients. Furthermore, mean platelet volume was declined and platelet distribution width was risen. Thus, hypothyroidism appears to increase the number of circulating platelets, especially the smaller ones.

Human T cells were studied with regard to the regulation of interleukin- 4 (IL-4) and IL-3 gene expression. IL-4 and IL-3 mRNA were undetectable in unstimulated T cells. On activation with the lectin concanavalin A (Con A), both IL-4 and IL-3 mRNA were expressed. Accumulation of IL-4 mRNA peaked after 6 to 12 hours, whereas IL-3 mRNA levels peaked after 3 to 6 hours of stimulation with Con A. Nuclear run-on assays showed a low constitutive transcription for both genes. The transcription rates were increased by Con A resulting in a peak for IL-4 after 1 hour (30% increase) and for IL-3 after 3 hours (40% increase) of Con A treatment. mRNA stability studies demonstrated that on activation with Con A both messages decayed with a half-life of approximately 90 minutes. No IL-4 or IL-3 mRNA expression was induced by the protein kinase C activator phorbol myristate acetate (PMA). However, PMA augmented the Con A- induced IL-4 and IL-3 mRNA accumulation. This was shown to be mediated at posttranscriptional level by a large increase in the stability of both messages (t 1/2 > 3 hours). The transcription rate of both genes was also enhanced by Con A+PMA and reached peak levels for IL-4 after 1 hour (90% increase) and for IL-3 after 3 hours (70% increase) of stimulation. Furthermore, it appeared that the induction of IL-4 mRNA was dependent on protein synthesis because cycloheximide (CHX) blocked the Con A- and Con A+PMA-induced expression of IL-4 mRNA. In contrast, CHX inhibited, but failed to completely block, the Con A- and Con A+PMA- induced IL-3 mRNA expression, whereas the expression of both genes was completely blocked by cyclosporine A. With regard to the secretion of IL-4 protein it was shown that it closely follows the accumulation of IL-4 mRNA. Taken together, the data show that expression of the IL-4 and IL-3 genes in human T cells is controlled by different activation pathways that affect the gene regulation at transcriptional and posttranscriptional levels.

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